THYROID NODULES: WHEN TO REFER “THE GOOD, BAD AND

THYROID NODULES: WHEN TO
REFER
“THE GOOD, BAD AND THE UGLY”
Dr. Nicola McLean M.D.,FRCPc
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QUESTIONS REGARDING THYROID
NODULES
1. What is the appropriate evaluation of clinically or
incidentally discovered thyroid nodule(s)?
2. What laboratory tests and imaging modalities are
indicated?
3. What is the role of fine-needle aspiration (FNA)?
4. What is the best method of long-term follow up of
patients with thyroid nodules?
5. What is the role of medical therapy of patients with
benign thyroid nodules?
6. How should thyroid nodules in children and pregnant
women be managed?
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7. WHEN TO REFER?
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Basic Thyroid
Anatomy
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Some necks are more difficult to examine
than others: History & Physical!
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THE
THYROID
EXAM
All Thumbs? You’re not
alone!
If you can feel it - then it
likely shouldn’t be there!
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46% of nodules > 1 cm on ultrasound,
escape clinical detection
in NA, 50-67 % asymptomatic thyroid
nodules found at autopsy
in areas not affected by nuclear fall-out, the
annual incidence of thyroid cancer is 1.2 to
2.6 cases per 100,000 in men and 2.0 to 3.8
cases per 100,000 in women
Eur J Endocrinol November 1, 2008 159 493-505
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PATHOPHYSIOLOGY
OF THYROID
NODULES
Benign 85-95%
Malignant 5-15%
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Papillary Cancer
Staging is age dependent ≥ 45
Follicular Cancer
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The Good News
In autopsy studies, clinically silent thyroid papillary
microcarcinomas (< 1 cm) have been reported
in up to 36 %
Follow-up studies of patients over 9 years shows no
metastases in patients with papillary microcarcinomas
< 0.8 cm
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Case 1
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HIGH RISK HISTORY
thyroid cancer in one or more first degree relatives
history of external beam radiation as a child or exposure to
ionizing radiation in childhood or adolescence
family history of medullary thyroid cancer
MEN
hemi-thyroidectomy for previous thyroid cancer
elevated calcitonin or known RET proto-oncogene mutation
positive PET scan (routinely not recommended)
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A 40 year-old woman presents with a recently discovered
painless thyroid nodule. There is no radiation history,
no dysphonia or dysphagia.
Examination reveals an easily palpable, firm solitary 2.5 cm
thyroid nodule and no cervical lymphadenopathy.
Would you order a thyroid ultrasound?
a. yes, always 89%
5%
b. no, never
c. it depends ! 6%
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Normal Thyroid Gland
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ATA Guidelines suggest that thyroid
ultrasound should be performed in all
patients with one or more suspected
thyroid nodules.
Next step?
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TSH
if the TSH is suppressed
Uptake and Scan
Thyroid
if the TSH is normal or elevated
FNA biopsy for most lesions > 1 cm in two
dimensions
if TSH is elevated: Hashimoto’s thyroiditis
has slightly higher risk (up to 30%)
Repplinger D, Bargren A, Zhang YW, Adler JT, Haymart M, Chen H 2008 Is
Hashimoto’s thyroiditis a risk factor for papillary thyroid cancer? J Surg Res 150:49–52.
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Routine use of serum thyroglobulin level is
not recommended (lacks sensitivity and
specificity)
role of serum calcitonin is controversial personal or FHx for MEN 2a or 2b
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“COLD” NODULES
NEED FNA BIOPSY
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Thyroid Cyst - The “Good”
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MIXED - THE “BAD” (POTENTIALLY)
spongiform
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“MIXED”
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ULTRASOUND GUIDED FNA
usually a 25 g needle
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ULTRASOUND CLUES TO MALIGNANCY
solid nodule
nodule halo absent
mixed solid and cystic
nodule
larger vertical than
horizontal dimensions
hypoechogenicity
micro-calcifications
mixed echogenicity
lymphadenopathy
ill-defined lesion
central vascularity
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WHEN TO BIOPSY
High risk history: with or without
suspicious sonographic features
> 5 mm
Abnormal cervical nodes
ALL
Microcalcifications present
≥ 1.0 cm
Solid nodule: Hypoechoic
Iso or Hyperechoic
Mixed Cystic and Solid: Suspicious
Not Suspicious
}
> 1.0 cm
≥ 1.0- 1.5 cm
≥ 1.5 - 2.0 cm
≥ 2.0 cm
Spongiform
≥ 2.0 cm
Purely Cystic
FNA Not Indicated
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NEXT STEP?
Thyroid Ultrasound
A 1.8 cm mixed solid and cystic nodule,
ill-defined medially, hypoechoic lesion
with micro-calcifications. There are also a
few sub-centimeter cysts scattered
throughout.
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THE “UGLY”
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ABNORMAL LYMPH NODES
larger vertical than horizontal dimensions
lack of fatty hilum
peripheral vascularity
micro calcifications
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WHAT IS THE ROLE OF MEDICAL THERAPY
FOR BENIGN THYROID NODULES?
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WHAT IS THE ROLE OF MEDICAL THERAPY
FOR BENIGN THYROID NODULES?
Not recommended: Thyroid hormone in doses that suppress
the serum TSH to subnormal levels may result in a decrease in
nodule size and may prevent the appearance of new nodules in
regions of the world with borderline low iodine intake.
Data in iodine-sufficient populations are less compelling, with
large studies suggesting that only about 17–25% of thyroid
nodules shrink more than 50%.
J Clin Endocrinol Metab 87:4154–4159.
J Clin Endocrinol Metab 87:4928– 4934.
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Management of
Thyroid
Nodules
Jameson, J. L. 2012. Minimizing
unnecessary surgery for thyroid
nodules. The New England journal of
medicine 367, (8) (Aug 23): 765-767,
Figure 1.
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INDICATIONS FOR OPERATIVE MANAGEMENT
AND REFERRAL
Lesions > 4 cm - compound,
solid or cystic
Multiple nodules associated with
a history of ionizing radiation
Single “cold” lesion
Nodules increasing in size
Recurrent Nodules
Nodules associated with
elevated calcitonin levels
FNA inconclusive / FNA
consistent with malignancy
Inadequate FNA after repeated
attempts
Symptomatic nodules: airway
compression, dysphagia,
cosmetic
High risk patients: male, young,
family history
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MANAGEMENT OF THYROID NODULES IN
PREGNANCY
evaluate same as for nonpregnant except no
radionucleotide scan
if FNA show DTC, can
repeat US at 24 wks - if
growth, then surgery / or
surgery in 2 nd trimester
before 24 wks
for PCT, can keep TSH 0.1
to 1.0
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HOW SHOULD THYROID NODULES BE
MANAGED IN CHILDREN?
In some studies, the
frequency of malignancy is
higher - 15 to 20 %
FNA is both sensitive and
specific
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IF BENIGN, WHY FOLLOW
Multinodular goitre has same risk of malignancy as solitary
nodules (one study showed otherwise) J Clin Endocrinol Metab 2006; 91:3411–
3417.
Up to 5 % false negative rate with FNA
Follow-up at 6 to 18 months Ultrasound &/or palpation > 50 %
increase in volume or 20 % increase in 2 dimensions or 20 %
increase in solid portion
⇊
FNA
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WHAT CLINICAL FEATURES MIGHT SUGGEST A
REFERRAL IS NEEDED ?
rapid growth / steady growth
( > 20% )
very firm nodule
fixation to adjacent structures
nodule > 4 cm
age <20 or > 70 years / male
paralysis of vocal cords/
dysphagia
regional lymphadenopathy/
metastases
“cold” on scan
Family History of MEN II
syndromes
prior history if head & neck
irradiation
partially cystic nodule
( “Mixed” )
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WHEN TO REFER
“Bad” and “Ugly” - suspicious by history and or ultrasound
confirmed cancer by FNA or Indeterminate pathology FLUS
Not cysts and not lesions < 0.5cm ⟹ follow
Unsure
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